Wednesday, February 29, 2012

NOTE: This guest blog was written by Ray Blanchard, Ph.D., who is an Adjunct Professor, Department of Psychiatry, University of Toronto and an Affiliate Scientist, Centre for Addiction and Mental Health, Toronto, Ontario, Canada. He is also the Chair of the Paraphilias Subworkgroup for the DSM-5 Work Group on Sexual and Gender Identity Disorders and was the 2010 recipient of ATSA’s Significant Achievement Award.

Proposed Changes for DSM-5 Diagnostic Criteria

Affecting Several or All Paraphilic Disorders

Ray Blanchard, Ph.D.

Toronto, ON Canada

The changes proposed by the DSM-5 Paraphilias Subworkgroup regarding the diagnostic criteria for Paraphilic Disorders may be divided into two categories: those that affect the diagnostic criteria for a single Paraphilic Disorder and those that affect the diagnostic criteria for all Paraphilic Disorders. This essay concerns proposed changes in the latter category.

Proposed Definitions, Labels, and Distinction between Paraphilias and Paraphilic Disorders

The term paraphilia denotes any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, consenting human partners between the ages of physical maturity and physical decline. In some circumstances, the criteria “intense and persistent” may be difficult to apply; these include the assessment of persons who are very old or medically ill, and who may not have “intense” sexual interests of any kind. In such circumstances, the term paraphilia may be defined as any sexual interest greater than or equal to normophilic sexual interests (Blanchard et al., 2009).

Some paraphilias primarily concern the individual’s erotic activities, and others primarily concern the individual’s erotic targets (Cantor, Blanchard, & Barbaree, 2009). Examples of the former would include intense and persistent interests in spanking, whipping, cutting, immobilizing, or strangulating another person, or an interest in these activities that equals or exceeds the individual’s interest in copulation or equivalent interaction with another person. Examples of the latter would include intense or preferential sexual interest in children, the elderly, or amputees (as a class), as well as intense or preferential interest in nonhuman animals, such as horses or dogs, or in inanimate objects, such as shoes or articles made of rubber.

One of the first questions addressed by the Paraphilias Subworkgroup was whether all paraphilias are ipso facto mental disorders. We took the position that they are not. We therefore proposed that the DSM-5 make a distinction between paraphilias and Paraphilic Disorders, as described below.

A Paraphilic Disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others in the past. A paraphilia is a necessary but not a sufficient condition for having a Paraphilic Disorder, and a paraphilia by itself does not automatically justify or require clinical intervention.

It was possible to implement the distinction between paraphilias and Paraphilic Disorders without making any changes to the basic structure of the diagnostic criteria as they had existed since DSM-III-R. In the diagnostic criteria set for each of the listed Paraphilic Disorders, Criterion A specifies the qualitative nature of the paraphilia (e.g., an erotic focus on children or on exposing the genitals to strangers), and Criterion B specifies the negative consequences of the paraphilia (distress, impairment, or harm—or risk of harm—to others). This format is exemplified by the proposed diagnostic criteria for Sexual Sadism Disorder:

A. Over a period of at least six months, recurrent and intense sexual arousal from the physical or psychological suffering of another person, as manifested by fantasies, urges, or behaviors.

B. The person has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause marked distress or impairment in social, occupational, or other important areas of functioning.

The change proposed for DSM-5 is that individuals who meet both Criterion A and Criterion B would now be diagnosed as having a Paraphilic Disorder. The word diagnosis would not be used in regard to individuals who meet Criterion A but not Criterion B, that is, individuals who have a paraphilia but not a Paraphilic Disorder. If an individual meets only Criterion A for a particular paraphilia—a circumstance that might arise when a benign paraphilia is discovered during the clinical investigation of some other condition—then the act of noting or reporting that the individual acknowledges the paraphilia should be referred to as ascertainment rather than diagnosis. Usage of the term ascertainment does not mean that an additional or a special step has been added to clinical assessment. It is simply a convenient way of avoiding the inappropriate word diagnosis when the individual has a paraphilia but not a Paraphilic Disorder.

The distinction between paraphilias and Paraphilic Disorders is one of the changes from DSM-IV-TR that applies to all atypical erotic interests. This approach leaves intact the distinction between normative and non-normative sexual behavior, which could be important to researchers, but without automatically labeling non-normative sexual behavior as psychopathological. An additional advantage of this approach is eliminating certain logical absurdities in the DSM-IV-TR. In that version, for example, a man could not be identified as having transvestism—however much he cross-dressed and however sexually exciting that was to him—unless he was unhappy about this activity or impaired by it (Blanchard, 2010b). This change in viewpoint is reflected in the diagnostic criteria sets by the addition of the word “Disorder” to all the paraphilias. Thus, DSM-IV-TR Fetishism becomes DSM-5 Fetishistic Disorder, Voyeurism becomes Voyeuristic Disorder, and so on.

Addition of Course Specifiers

The second overarching change from DSM-IV-TR is the addition of the course specifiers, “In a Controlled Environment” and “In Remission,” to the diagnostic criteria sets for all the Paraphilic Disorders. These specifiers were added in response to clinicians’ complaints that the DSM-IV-TR and earlier versions provided no mechanism for indicating important changes in the individual’s status. There is no expert consensus about whether a longstanding paraphilia can disappear spontaneously or be removed by therapy. There is less argument that consequent psychological distress, psychosocial impairment, or the propensity to do harm to others can be ameliorated by therapy or reduced to acceptable levels. Therefore, the “In Remission” course specifier was written so as to indicate remission from a Paraphilic Disorder. It is silent in regard to changes in the presence of the paraphilic interest per se. The intended meaning of remission is clarified in each of the diagnostic criteria sets with a parenthetical expression: “In Remission (No Distress, Impairment, or Recurring Behavior for Five Years and in an Uncontrolled Environment).” The other course specifier, “In a Controlled Environment,” was included because the propensity of an individual to act on paraphilic urges may be more difficult to assess objectively when the individual has no opportunity to act on such urges.

Changes and Continuities in Criterion A

The DSM-IV and DSM-IV-TR used the identical wording format in Criterion A for all Paraphilias: “Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving [the paraphilic focus].” Only the specification of the paraphilic focus varied from one paraphilia to another, for example, “nonliving objects” (Fetishism) and “exposure of one’s genitals” (Exhibitionism).

The wording format proposed for Criterion A for all DSM-5 paraphilias is essentially similar: “Over a period of at least six months, recurrent and intense sexual arousal from [the paraphilic focus], as manifested by fantasies, urges, or behaviors.” The purpose of this change was to clarify the relations of sexual fantasies, urges, and behaviors to each other and to the corresponding, underlying paraphilia. Fantasies, urges, and behaviors are (directly or indirectly) observable indicators of a psychological trait—a paraphilia—that cannot itself be observed using present technologies and perhaps cannot be observed in principle. The writer has previously expressed this conceptualization of paraphilias in somewhat different language: “I regard paraphilias . . . as erotic preferences or orientations that inhere in the individual and that have some existence independent of specific, observable actions” (Blanchard, 2010a, p. 310).

Changes and Continuities in Criterion B

In comparison with Criterion A, Criterion B (the distress and impairment criterion) has had a rather variable history. DSM-III-R used the identical wording format in Criterion B for all Paraphilias: “The person has acted on these urges, or is markedly distressed by them.” DSM-IV also used the identical format for all paraphilias, but it was completely different from the one applied in DSM-III-R: “The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

DSM-IV-TR used two different formats: One for Paraphilias whose satisfaction does not entail the involvement of nonconsenting others and one for Paraphilias that do involve nonconsenting others. Criterion B for Fetishism, Sexual Masochism, and Transvestic Fetishism remained exactly as it had been in DSM-IV. Criterion B for Exhibitionism, Frotteurism, Pedophilia, and Voyeurism reinstated a clause about acting on the basis of the paraphilia and thus returned to a formula very similar to that used in DSM-III-R: “The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.” Criterion B for Sadism was the same statement with an additional qualifier: “The person has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.”

The B criteria proposed for DSM-5 follow the two-version pattern established in DSM-IV-TR. The version of Criterion B for Fetishistic Disorder, Sexual Masochism Disorder, and Transvestic Disorder reads: “The fantasies, sexual urges, or behaviors cause marked distress or impairment in social, occupational, or other important areas of functioning.” The version of Criterion B for Exhibitionistic Disorder, Frotteuristic Disorder, Sexual Sadism Disorder, and Voyeuristic Disorder reads: “The person has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause marked distress or impairment in social, occupational, or other important areas of functioning.” There is a slight variation of Criterion B for Pedophilic Disorder, because a nonconsenting person (in the common-language sense of unaware, unwilling, or resisting) is not inherent to the sexual objective. Thus: “The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or impairment in social, occupational, or other important areas of functioning.”

The crucial point of this section is that the proposed diagnostic criteria for DSM-5, exactly like the diagnostic criteria for DSM-IV-TR, make it possible to diagnose a patient with a specific paraphilia on the sole grounds that he has offended against multiple victims in a way characteristic of that paraphilia, whether he acknowledges that paraphilia or not. The recurrent behavior constitutes clinical grounds for inferring that the paraphilia is present (satisfying Criterion A) and, at the same time, it demonstrates that the paraphilically motivated behavior is causing distress, harm, or risk of harm to others (satisfying Criterion B).

The question of how much sexually offending behavior of the same type is necessary to diagnose the corresponding Paraphilic Disorder in a patient who verbally denies that disorder has traditionally been left to clinical judgment. The available research indicates that a threshold of three or more different victims age 14 or younger can be used to diagnose Pedophilic Disorder with a high degree of specificity, that is, 90% or more (Blanchard, 2010c, 2011). The writer knows of no published research investigating a diagnostic threshold based on a patient’s total number of sexual interactions with the same child or on the length of time (in weeks, months, or years) during which a patient interacted sexually with the same child.

Wednesday, February 22, 2012

This blog post features commentary by ATSA member and Minnesota resident/clinician Jon Brandt.

Doubts about SVP Programs

Jon Brandt, MSW, LICSW

St. Paul, MN

Recently there have been some excellent commentaries on the ATSA LIST about the state of sexual offender civil commitment (SOCC) and SVP programs in the US and Canada. With the pending discharge from SOCC in Minnesota of only the second guy in 20 years, this is a hot issue here. Not surprisingly, some state legislators are already trying to figure out how to block the release of 64-year-old Clarence Opheim.
For 20 years, Minnesota’s SOCC program has been a one-way door, with releases determined by political fiat rather than by therapists or judicial review. The SDP threshold into SOCC in Minnesota (MN Stat 253B.02 (18c)) is frighteningly low and the obstacles out are impossibly high. The current census at Minnesota’s SOCC facilities, the Minnesota Sex Offender Program (MSOP) is about 640. By 2020, MN DHS projects 1,100 clients.

At least in Minnesota, my experience is that most of the professional, competent staff at MSOP are trying to provide effective treatment to clients. However, it is not lost on either clients or staff that there is an intellectual dishonesty about treatment goals that no one has ever completed. When treatment is unending, can we expect clients to maintain endless motivation? MSOP reports an 80% treatment participation rate; evidence that dedicated staff and hopeful clients are trying to make the best of current circumstances. I do not think it is a moral abdication for clinical staff to provide services to clients while supporting and encouraging reforms and participating in the academic debates about SOCC.

Just a year ago, in March 2011, The Minnesota Office of the Legislative Auditor released an evaluation on the Civil Commitment of Sex Offenders in Minnesota. Like a similar 2011 legislative report just released in Virginia, it offers a review and critique of how MSOP is operating, relative to legislative intent. Needless to say, it is difficult to have outcome data without any “outs.”

The Minnesota report is over 100 pages, but there is a summary of recommendations starting on page 93. The summary, however, does not do justice to the narrative, which actually has a candid discussion about some of the problems and weaknesses in the MSOP program. The authors did not sidestep the issue of morale and client motivation for a program that operates like the Eagles' Hotel California – “you can never leave.”

I appreciate the insightful commentaries on SVP programs recently posted by Merrill Main and David Thornton on the ATSA-LIST. There was much to agree with, but I disagree with Dr. Thornton that, "you can only work with sexual offenders in the USA if you are prepared to work as part of a system that is substantially less just and less effective than it should be. Your choice then is whether you either withdraw from that system as a whole or work within it trying to incrementally shift it in the direction of becoming less unjust and less ineffective."

Thornton has expressed his views often enough on the ATSA-LIST and in other professional forums to leave no doubt that he is an advocate for the better management of sexual offenders, but I think it is BECAUSE we know that we are working in a broken system that we should neither withdraw from the system nor acquiesce to "incremental” changes.

Per capita, Minnesota has the highest SOCC rate in the world, and has had only one provisional discharge in its 20-year history. It was unsuccessful, his release was revoked, and he died at MSOP. If Mr. Opheim is able to avoid revocation of his discharge, he will be the first-ever MSOP client to not leave SOCC in a body bag. SOCC in Minnesota and elsewhere is badly broken and needs more than incremental change.

In January of this year, MN DHS and the William Mitchell Law School co-sponsored a symposium on SOCC, comparing systems in four states (MN, WI, TX, NY). There was no consensus on whether Minnesota should look at "more successful" models of SOCC, or whether we should consider the possibility that the 30 states in the US and almost all other countries around the world who do not have SOCC might be the model to follow. Every state/country has dangerous offenders; how are they managed without SOCC? With all due consideration for the dangerousness of those men on the morally depraved end of the scale, how many guys at the other end of the continuum should not be under SOCC?

Prior to SOCC, the last widespread use of preventive detention in the USA was when all three branches of our federal government approved the roundup of Japanese-Americans during WWII. After Pearl Harbor, “internment” was popular with the public and, with roots in anger, fear, and misinformation, it was legally justified on concerns for public safety. At the time, there were undoubtedly a lot more discussions about who qualified as “Japanese” and the logistics of mass incarceration, than there likely were about triage for risk or concerns about social injustice. Surely, anyone who spoke to the idea that preventive detention might be a misguided reaction to overblown fear had a small audience. While, perhaps, some argued for incremental changes to the living conditions at internment camps, the existence of the camps themselves were challenged by too few.

Internment was wrong, and most educated, informed people knew it. Nevertheless, leadership caved and public policy was driven by widespread hysteria. If Japanese internment is an unflattering comparison, that does not make the analogy invalid; in fact it makes the point stronger. If we will use preventive detention without considerations for efficacy or social injustice with Japanese-Americans who did not do anything to warrant detention, is it any wonder that the public seems entirely “comfortable" with using preventive detention for sexual offenders? If hindsight is 20/20, when we look back at SOCC many years in the future, will we be proud of the roles that we had today?

William Mitchell Law School Dean Eric Janus warned 20 years ago that SOCC was both deceptively enticing and deeply flawed. He predicted that SOCC would over-reach, compromise legal integrity, and foster misguided solutions to complicated social problems. Professor Janus wrote about this in his 2006 book, "Failure to Protect: America's Sexual Predator Laws and the Rise of the Preventive State." Some of his arguments were laid out in a 2008 journal article. Janus appears to be correct in his prophesy of “build it and they will come.” At the symposium last month Janus issued another warning, that SOCC is an "impending train wreck."

Washington became the first state with SOCC in 1990. Like in Minnesota, the impetus was a couple of high-profile heinous sex crimes. SOCC has now been enacted,in some form, in 20 states. The US Supreme Court had doubts about sexual civil commitment in 1997 when justices approved it, in concept, by a narrow 5-4 vote inKansas v. Hendricks. Kansas v. Crane, decided in 2002 by a 7-2 vote, clarified the Hendricks decision in regard to volition. A read of the opinions in these cases reveals how fluid the legal underpinnings of civil commitment are. It is noteworthy that Justice Breyer, in his dissenting opinion in the Hendricks decision, refers to an Amicus Brief filed by ATSA, attesting to the treatability of sexual offenders. If one justice in the majority on the Hendricks decision had joined the dissenting justices, SOCC would not exist as we know it today. If the courts, upon further review, find SOCC in practice to effectively be prison in disguise, the courts may find SOCC to be unconstitutional. Indeed, we should have doubts about SVP programs, and as a profession be prepared to offer viable, effective alternatives.

If professionals who work with sexual offenders do not challenge the politics, misinformation, and misguided management of SOCC, where is a more credible voice going to come from? In an area of public policy where reason is often eclipsed by emotion, ATSA members may be in the best position to know the research, understand competing principles, and advocate for sound rationales. If forensic psychology with sexual offenders is being dominated more by forensics than psychology, I would suggest that the tail might be wagging the dog.

A 2012 report just released on Sex Offender Recidivism in Connecticut confirms that recidivism for sexual offenders continues to be extraordinarily low. In a five-year review of 14,400 men released from prison in 2005, of the 746 parolees who had served a prison term for a sex crime, only 27, or 3.6 percent were arrested and charged with a new sex crime; 20, or 2.7 percent were convicted; and 13, or 1.7 percent were returned to prison with a sentence for a new sex crime. (Incidentally, the report has excellent demographic data.)

In contrast, the report indicates that overall recidivism for general parolees in the same period was 78.6 percent arrested, 69.3 percent convicted, and 49.8 percent returned to prison with new sentences. It is noteworthy that the report also reveals that a large number of paroled sexual offenders reoffended in other ways, but not sexually, which is what sexual offender management and SOCC is targeting. Still this report supports the conclusions of other research—that sexual recidivism is exceptionally low and there is something materially different between most sexual offenders and most “common criminals”.

Consider the data in the CT report in the context of actuarial risk tools. Only 3.6% of 746 paroled sex offenders were charged with a new sex crime. Is it any wonder that actuarial risk tools are having a difficult time determining which 27 guys out of 746 parolees will sexually re-offend? The report offers some clues, but they are not likely to be statistically significant. It is widely believed that most actuarial tools, in practice, are over-reaching the underlying science. How does this affect the rate of SOCC?

Furthermore, consider the implications of this CT report for SO registration. Add these new Connecticut findings to a 2008 New York State review of 170,000 arrest records for sexual offenses over a 20-year period. The review determined that 95% were first time sex offenders. As a matter of good public policy, does a reoffense rate of 4-5% justify the registration and tracking of the other 95% of sexual offenders?

A growing body of national research is beginning to arrive at a consensus similar to findings in New Jersey, that SORNA is at best a misguided solution; at worst contributing to the “social death” of sexual offenders, not cost effective, and by missing 95% of sexual offending not effectively making society safer. If sexual offender registration is severely over-reaching in the management of low-risk sexual offenders, is it not likely that the same risk management system might also be over-reaching in SOCC?

How many men with sexual offenses are getting caught in the SVP nets, not because they are actually dangerous, but because what they did is exceptionally offensive? What level of false positives is acceptable? The cost to taxpayers, lost productivity, and social injustice cannot be quantified.

If Clarence Opheim is provisionally discharged from MN SOCC next month, morale at MSOP will rise and scores of clients will reinvest in treatment. Hundreds of MSOP staff and 639 other clients are pinning their hopes on one man’s success. Every day that Mr. Opheim remains offense-free, survives the public wrath, holds up to the scrutiny of the media, and professionals do not overreact to minor violations, will build success. Stakeholders on both sides of the razor-wire will be watching to see if he is able to put 20 years of sex offender specific treatment into practice in a “real social environment,” or if he has forgotten how to function in the real world.

The state might indefinitely have to provide housing and facilitate employment. “Ex-con” or “Sex Offender” is a tough enough label but being tagged the “worst of the worst” might be a deal-breaker on a resume or a housing application. While I’m intending to be only a little bit cynical, without significant reforms, most adjudicated or convicted sexual offenders today, no matter how successful their efforts in the future, will never escape their past. That will be especially true for every guy coming out of SOCC.

It is not just in everyone’s interest that Mr. Opheim succeeds; it is imperative. Consider the alternative: If the second of only two discharges in MSOP history fails, for any reason, both failures will be seen as a malfunction of both MSOP and SOCC. A second unsuccessful discharge is not only likely to have far-reaching consequences for sexual offender management in Minnesota; a seismic “thud” may well be heard at ATSA listening posts across the country. In addition, it would be hard for the courts to ignore.

SOCC in Minnesota may now be painted into a corner. In the interest of public safety we may have compromised Constitutional protections beyond integrity. Perhaps Ben Franklin’s quote is apt, that “those who would give up essential liberty to purchase a little safety deserve neither liberty nor safety.” This might be part of the “train wreck” scenario envisioned by Janus.

The successful release of Mr. Opheim and other men under SOCC will be something to celebrate by all of us in this field that believe in effective treatment, the power of redemption, and the principles of social justice. But, going forward, if we are going to effectively manage sexual offenders, we need a significant paradigm shift.

We have very solid empirical evidence to challenge current misguided public policies. We need to get good research to the right folks. We need to infuse policy makers with the necessary information for bureaucracies to champion productive recommendations into meaningful change. Many ATSA members are doing the “heavy lifting” of trying to bring good research, balanced perspectives, and reasoned initiatives by writing and speaking to the media and at public hearings in the US and Canada.

We should all push past some inherent reticence that interferes with our ability to professionally speak up, take a stand, or find a place at the table with other stakeholders who share our common goals of making society safer. If we use our knowledge and expertise to educate the public, inform our colleagues, and persuade policymakers that best practices should emanate from good science, we might not have to settle for incremental changes. We can help create new paradigms.

A postscript: There is a sobering caveat contained in the Connecticut report. The data was based on offenders released from prison during 2005. In 2007 was the horrible home invasion murder of the Petit family by two CT parolees. In the months following, the state’s parole system stopped functioning, the prison system grew by almost 1,000 inmates, and remand rates soared. This is similar to what happened in Minnesota in 2003 when Dru Sjodin was murdered by a Minnesota parolee. The following year, the referral rate for SOCC in Minnesota went from an average annual rate of 26, to 235. Since then, SOCC referrals have remained at an average annual rate of 140. Horrendous events resulted in Adam Walsh, Jacob Wetterling, Megan Kanka, Dru Sjodin, and too many other murdered individuals becoming the namesakes of Congressional Acts. This should remind us of the urgent and ongoing need to do much, much more on the prevention side.

Kieran McCartan, PhD

Chief Blogger

David Prescott, LICSW

Associate blogger

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The Association for the Treatment of Sexual Abusers (http://atsa.com/) is an international, multi-disciplinary organization dedicated to preventing sexual abuse. Through research, education, and shared learning ATSA promotes evidence based practice, public policy and community strategies that lead to the effective assessment, treatment and management of individuals who have sexually abused or are risk to abuse.

The views expressed on this blog are of the bloggers and are not necessarily those of the Association for the Treatment of Sexual Abusers, Sexual Abuse: A Journal of Research & Treatment, or Sage Journals.

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